Surg Today DOI 10.1007/s00595-014-1004-3
HOW TO DO IT
One‑step venous reconstruction using the donor’s round ligament in right‑lobe living‑donor liver transplantation Takeo Toshima · Toru Ikegami · Yoshihiro Matsumoto · Shohei Yoshiya · Norifumi Harimoto · Yo‑ichi Yamashita · Tomoharu Yoshizumi · Tetsuo Ikeda · Ken Shirabe · Yoshihiko Maehara
Received: 27 August 2012 / Accepted: 12 May 2014 © Springer Japan 2014
Abstract We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor’s round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor’s round ligament graft in RL-LDLT. Keywords Umbilical vein · Venous reconstruction · Right lobe · Liver transplantation Abbreviations IRHV Inferior right hepatic vein IVC Inferior vena cava LDLT Living-donor liver transplantation MHV Middle hepatic vein RL Right lobe
Introduction Living-donor liver transplantation (LDLT) has become an important treatment modality for end-stage liver disease since it was first reported in 1989 [1]. With the increase in the number of adult LDLT cases, the harvested graft volume has increased from a lateral segment, to the left lobe and then to the right lobe (RL) [2, 3]. Since the modified RL graft was first described by Lee et al. [4] in 2002, some reports have described reconstruction of the MHV tributaries, V5 and V8, and the inferior right hepatic vein (IRHV) to prevent RL congestion. We previously demonstrated the feasibility of using autologous interposition vein grafts, such as the portal vein, saphenous vein, inferior vena cava, inferior mesenteric vein and internal jugular vein [5, 6]. However, harvesting these interposition grafts from recipients may increase their surgical risk, and the recipient’s vessels may be unsuitable because they are sometimes thin or fragile because of systemic illness. The round ligament is a remnant of the fetal umbilical vein [7]. Some recent reports have described the successful use of the round ligament for patch repair of an injured bile duct or for inferior vena cava (IVC) reconstruction [8, 9]. We herein present the first report describing venous reconstruction using a donor’s opened round ligament as a patch graft in RL-LDLT, using a technique that is easy and safe.
Case report T. Toshima (*) · T. Ikegami · Y. Matsumoto · S. Yoshiya · N. Harimoto · Y. Yamashita · T. Yoshizumi · T. Ikeda · K. Shirabe · Y. Maehara Department of Surgery and Science, Graduate School of Medicine, Kyushu University, 3‑1‑1 Maidashi, Higashi‑ku, Fukuoka 812‑8582, Japan e-mail: [email protected]‑u.ac.jp
Our patient was a 23-year-old male with end-stage liver disease secondary to primary sclerosing cholangitis and concurrent ulcerative colitis. Dynamic computed tomography revealed an atrophic portal vein which was unsuitable for venous reconstruction. The donor was his healthy
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Surg Today
good outflow from the posterior segment. Intraoperative and postoperative Doppler ultrasound examinations confirmed excellent flow in the reconstructed IRHV. The anhepatic, cold ischemic and warm ischemic times were 71, 125 and 45 min, respectively. The total length of the operation was 15 h and 3 min. The estimated blood loss was 895 mL, with no blood transfusion required. The immediate graft function was excellent, and hemostasis was quickly achieved. All Doppler ultrasound examinations on postoperative days 1–14 revealed excellent results. The patient was discharged from hospital 14 days after LDLT without complications. The patency of the reconstructed IRHV was confirmed by dynamic computed tomography at one year after LDLT.
Discussion Fig. 1 Venous reconstruction using the donor’s round ligament as a patch graft. The harvested round ligament was opened on the back table, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed for use as a patch graft
48-year-old mother. The harvested graft had a large drainage area from the IRHV, accounting for 91 mL (16.3 % of the RL volume) by preoperative 3D-CT volumetry simulation (Resion Growing Software Version 0.5a; Hitachi Medical Corporation, Chiba, Japan). The RL graft was harvested using standard procedures [10]. After making bilateral subcostal laparotomy incisions with midline extension, a 8-cm long segment of the donor’s round ligament was harvested. On the back table, the harvested round ligament was opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed for use as a patch graft. First, the RHV of the graft, which was 3.0 cm in diameter, was anastomosed endto-end to the umbilical vein patch using continuous 6-0 PDS-II™ sutures (Ethicon; Somerville, NJ, USA). Next, the IRHV of the graft, which was 1.0 cm in diameter, was anastomosed to an independent hole made in the wall on the other side of the patch using continuous 6-0 PDS-II™ sutures, to form a bridged vascular patch for anastomosis to the IVC (Fig. 1). Implantation of the RL graft was performed as follows: a hole measuring 3.0 × 7.0 cm, coinciding with the size of the patch, was made in the anterior wall of the recipient’s IVC. The patch graft was sutured to the defect in the IVC, using continuous intraluminal 5-0 PDS-II™ sutures, with the lumen of the round ligament sutured to the lumen of the IVC. Portal vein anastomosis was then performed using continuous 6-0 PDS-II™ sutures incorporating growth factor. The interposition graft filled promptly and provided
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We herein reported a case in which a donor’s opened round ligament, which is a remnant fetal umbilical vein, was used as a venous patch graft for IRHV reconstruction and anastomosis to the IVC. This is an easy, safe and useful technique to facilitate potentially challenging LDLT surgery. Since Lee et al. [4] first suggested using a modified RL graft in 2002, many types of autologous interposition vein grafts have been used. We previously described a technique which used an autologous portal vein graft to reconstruct MHV tributaries and the IRHV [4]. One of the crucial problems associated with using RL grafts without the MHV is liver dysfunction caused by excessive congestion [4–6]. Some reports have described the impact of liver congestion [11]. For example, Mizuno et al. [12] demonstrated that the liver regeneration is significantly poorer in a congested area compared with a non-congested area. Congestion should be prevented as much as possible by reconstruction of the IRHV with a suitable interposition graft. However, a suitable vascular graft is not always readily available. As transverse closure of a longitudinal defect does not seem to be ideal for maintaining the cylindrical shape of the IVC, longitudinal closure should be performed. Kubota et al. [13] stated that closure of a 20–30 % defect in the IVC resulted in a 49–64 % decrease in the cross-sectional area. Therefore, patch reconstruction to maintain the flow volume is justified. Various prosthetic and autovenous patch grafts, pericardial grafts and peritoneo-fascial grafts have been described for IVC reconstruction [14–17]. The disadvantages of these methods include the need for additional surgery, the sacrifice of major visceral vessels and the risks of infection. Prosthetic grafts have the advantage of being available in various sizes and can even be used for total replacement of the vena cava, but they carry some risks of infection and thrombosis [14, 15]. The harvesting of autografts, including pericardial
Surg Today
and peritoneo-fascial grafts, always requires additional surgery [14–17]. Harvesting a pericardial patch requires thoracotomy [17]. Harvesting other venous grafts, including saphenous vein, inferior mesenteric vein and internal jugular vein grafts, may result in congestive complications in the areas originally drained by these veins [14, 15]. In contrast, the round ligament is universally available, is of a suitable length and can be harvested during laparotomy without causing the donor any harm [7–9]. There is no need for additional exposure to harvest the round ligament. In addition, it has been shown that the lumen of the round ligament has a mesothelial lining [18]. Rocca et al. [19] and Ribbe et al. [20] reported that such a mesothelial lining is antithrombogenic and promotes endothelialization. These characteristics of the opened round ligament could be advantageous for use as a vascular patch graft, including as a graft in the low-pressure venous system. Yamanaka et al. [21] were the first to demonstrate the feasibility of using the round ligament as a vascular graft. They mainly used the unopened round ligament for reconstruction of the portal system in seven cases of hepatopancreatobiliary surgery. Only one of these cases developed postoperative superior mesenteric vein obstruction and died before hospital discharge, whereas good postoperative patency of the portal system was achieved in the other six cases. Watanabe et al. [8] also reported successful use of the round ligament for patch repair in combination with stents in four cases of iatrogenic injury to the biliary tract, including clipping of the cystic duct, a defect in the common bile duct and right hepatic duct and irregular incision of the common bile duct. None of these patients experienced any further complications. For right-lobe grafts in LDLT, we prioritize the use of the explanted portal vein or internal jugular vein as a tubular conduit graft for reconstructing MHV tributaries, as described previously [5, 6]. Shunt vessels, including the dilated paraumbilical vein, can be used for the same purpose as the second candidate. In addition, a remnant explanted portal vein or an opened round ligament is used as a bridge-shaped patch joining the RHV and the IRHV or as a cuff around the venous orifices. A recent histological analysis of the opened round ligament [22] revealed that only approximately one-third of the round ligaments in adults contained an open umbilical vein, whereas the other two-thirds did not. The opened round ligaments could be used as venous patch grafts without causing thrombosis in the short follow-up periods in those studies; however, the mechanical dilatation of the round ligaments or remnant umbilical veins disrupted the intimal layer and exposed the subintimal layers. Therefore, the limitations of using a round ligament as a venous patch are that it has not been elucidated whether these disruptions of the intimal layers by manual dilatation cause thrombosis
or stenosis in the reconstructed veins during the long term. Further studies with a greater accumulation of cases and longer follow-up are necessary. Our results are not sufficient to allow us to conclude that using a round ligament patch is more effective for achieving long-term patency than other techniques. However, the potential benefits of the procedure warrant further evaluation of this technique, including experience with more cases. Conflict of interest The authors declare no conflicts of interest.
References 1. Raja S, Nery JR, Mies S. Liver transplantation from live donors. Lancet. 1989;2:497. 2. Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Ijichi H, et al. Feasibility of left lobe living donor LT between adults: an 8-year, single-center experience of 107 cases. Am J Transplant. 2006;6:1004. 3. Lee S, Park K, Hwang S, et al. Congestion of right liver graft in living donor liver transplantation. Transplantation. 2007;71:812–4. 4. Gyu Lee S, Min Park K, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation. 2002;74:54–9. 5. Ikegami T, Soejima Y, Taketomi A, et al. Explanted portal vein grafts for middle hepatic vein tributaries in living-donor liver transplantation. Transplantation. 2007;84:836–41. 6. Soejima Y, Ueda N, Fukuhara T, et al. One-step venous reconstruction for a right lobe graft with multiple venous orifices in living donor liver transplantation. Liver Transplant. 2008;14:706–8. 7. Emre S, Schwartz ME, Katz E, Miller CM. Liver resection under total vascular isolation. Variations on a theme. Ann Surg. 1993;217:15–9. 8. Watanabe M, Yamazaki K, Tsuchiya M, et al. Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract. J Hepatobiliary Pancreat Surg. 2007;14:270–5. 9. Ikegami T, Shimada M, Imura S, et al. Beneficial use of the round ligament as a patch graft for vena cava reconstruction. J Hepatobiliary Pancreat Surg. 2008;15:581–4. 10. Shimada M, Shiotani S, Ninomiya M, et al. Characteristics of liver grafts in living-donor adult liver transplantation: comparison between right- and left-lobe grafts. Arch Surg. 2002;137:1174–9. 11. Yonemura Y, Taketomi A, Soejima Y, et al. Validity of preoperative volumetric analysis of congestion volume in living donor liver transplantation using three-dimensional computed tomography. Liver Transplant. 2005;11:1556–62. 12. Mizuno S, Iida T, Yagi S, et al. Impact of venous drainage on regeneration of the anterior segment of right living-related liver grafts. Clin Transplant. 2006;20:509. 13. Kubota K, Makuuchi M, Kobayashi T, et al. Reconstruction of the inferior vena cava using a hepatic venous patch obtained from resected liver. Hepatogastroenterology. 1997;44:378–9. 14. Azoulay D, Andreani P, Maggi U, et al. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg. 2006;244:80–8. 15. Ohwada S, Hamada K, Kawate S, et al. Left renal vein graft for vascular reconstruction in abdominal malignancy. World J Surg. 2007;31:1215–20. 16. Krom RA. Liver transplantation with reconstruction of infrarenal vena cava and iliac veins. Liver Transplant. 2004;10:951–2.
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17. Togo S, Tanaka K, Endo I, et al. Caudate lobectomy combined with resection of the inferior vena cava and its reconstruction by a pericardial autograft patch. Dig Surg. 2002;19:340–3. 18. Tesch C, Henne-Bruns D, Holstein AF. Open lymph vessels of the ligamentum falciforme hepatis in the human. Langenbecks Arch Chir. 1990;375:130–4. 19. Rocca JP, Rodriguez-Davalos MI, Burke-Davis M, et al. Livingdonor hepatectomy in right-sided round-ligament liver: importance of mapping the anatomy to the left medial segment. J Hepatobiliary Pancreat Surg. 2006;13:454–7. 20. Ribbe EB, Alm P, Hallberg E, et al. Evaluation of perito neal tube grafts in the inferior vena cava of the pig. Br J Surg. 1998;75:357–60.
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Surg Today 21. Yamanaka N, Yasui C, Yamanaka J, et al. Recycled use of reopened umbilical vein for venous reconstruction in hepatopancreatobiliary surgery. J Am Coll Surg. 2000;190:497–501. 22. Ikegami T, Wang H, Imai D, Bekki Y, Yoshizumi T, Yamashita YI, Toshima T, Soejima Y, Shirabe K, Maehara Y. Pathological analysis of opened round ligaments as venous patch grafts in living donor liver transplantation. Liver Transplant. 2013;19(11):1245–51.
HOW TO DO IT
One‑step venous reconstruction using the donor’s round ligament in right‑lobe living‑donor liver transplantation Takeo Toshima · Toru Ikegami · Yoshihiro Matsumoto · Shohei Yoshiya · Norifumi Harimoto · Yo‑ichi Yamashita · Tomoharu Yoshizumi · Tetsuo Ikeda · Ken Shirabe · Yoshihiko Maehara
Received: 27 August 2012 / Accepted: 12 May 2014 © Springer Japan 2014
Abstract We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor’s round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor’s round ligament graft in RL-LDLT. Keywords Umbilical vein · Venous reconstruction · Right lobe · Liver transplantation Abbreviations IRHV Inferior right hepatic vein IVC Inferior vena cava LDLT Living-donor liver transplantation MHV Middle hepatic vein RL Right lobe
Introduction Living-donor liver transplantation (LDLT) has become an important treatment modality for end-stage liver disease since it was first reported in 1989 [1]. With the increase in the number of adult LDLT cases, the harvested graft volume has increased from a lateral segment, to the left lobe and then to the right lobe (RL) [2, 3]. Since the modified RL graft was first described by Lee et al. [4] in 2002, some reports have described reconstruction of the MHV tributaries, V5 and V8, and the inferior right hepatic vein (IRHV) to prevent RL congestion. We previously demonstrated the feasibility of using autologous interposition vein grafts, such as the portal vein, saphenous vein, inferior vena cava, inferior mesenteric vein and internal jugular vein [5, 6]. However, harvesting these interposition grafts from recipients may increase their surgical risk, and the recipient’s vessels may be unsuitable because they are sometimes thin or fragile because of systemic illness. The round ligament is a remnant of the fetal umbilical vein [7]. Some recent reports have described the successful use of the round ligament for patch repair of an injured bile duct or for inferior vena cava (IVC) reconstruction [8, 9]. We herein present the first report describing venous reconstruction using a donor’s opened round ligament as a patch graft in RL-LDLT, using a technique that is easy and safe.
Case report T. Toshima (*) · T. Ikegami · Y. Matsumoto · S. Yoshiya · N. Harimoto · Y. Yamashita · T. Yoshizumi · T. Ikeda · K. Shirabe · Y. Maehara Department of Surgery and Science, Graduate School of Medicine, Kyushu University, 3‑1‑1 Maidashi, Higashi‑ku, Fukuoka 812‑8582, Japan e-mail: [email protected]‑u.ac.jp
Our patient was a 23-year-old male with end-stage liver disease secondary to primary sclerosing cholangitis and concurrent ulcerative colitis. Dynamic computed tomography revealed an atrophic portal vein which was unsuitable for venous reconstruction. The donor was his healthy
13
Surg Today
good outflow from the posterior segment. Intraoperative and postoperative Doppler ultrasound examinations confirmed excellent flow in the reconstructed IRHV. The anhepatic, cold ischemic and warm ischemic times were 71, 125 and 45 min, respectively. The total length of the operation was 15 h and 3 min. The estimated blood loss was 895 mL, with no blood transfusion required. The immediate graft function was excellent, and hemostasis was quickly achieved. All Doppler ultrasound examinations on postoperative days 1–14 revealed excellent results. The patient was discharged from hospital 14 days after LDLT without complications. The patency of the reconstructed IRHV was confirmed by dynamic computed tomography at one year after LDLT.
Discussion Fig. 1 Venous reconstruction using the donor’s round ligament as a patch graft. The harvested round ligament was opened on the back table, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed for use as a patch graft
48-year-old mother. The harvested graft had a large drainage area from the IRHV, accounting for 91 mL (16.3 % of the RL volume) by preoperative 3D-CT volumetry simulation (Resion Growing Software Version 0.5a; Hitachi Medical Corporation, Chiba, Japan). The RL graft was harvested using standard procedures [10]. After making bilateral subcostal laparotomy incisions with midline extension, a 8-cm long segment of the donor’s round ligament was harvested. On the back table, the harvested round ligament was opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed for use as a patch graft. First, the RHV of the graft, which was 3.0 cm in diameter, was anastomosed endto-end to the umbilical vein patch using continuous 6-0 PDS-II™ sutures (Ethicon; Somerville, NJ, USA). Next, the IRHV of the graft, which was 1.0 cm in diameter, was anastomosed to an independent hole made in the wall on the other side of the patch using continuous 6-0 PDS-II™ sutures, to form a bridged vascular patch for anastomosis to the IVC (Fig. 1). Implantation of the RL graft was performed as follows: a hole measuring 3.0 × 7.0 cm, coinciding with the size of the patch, was made in the anterior wall of the recipient’s IVC. The patch graft was sutured to the defect in the IVC, using continuous intraluminal 5-0 PDS-II™ sutures, with the lumen of the round ligament sutured to the lumen of the IVC. Portal vein anastomosis was then performed using continuous 6-0 PDS-II™ sutures incorporating growth factor. The interposition graft filled promptly and provided
13
We herein reported a case in which a donor’s opened round ligament, which is a remnant fetal umbilical vein, was used as a venous patch graft for IRHV reconstruction and anastomosis to the IVC. This is an easy, safe and useful technique to facilitate potentially challenging LDLT surgery. Since Lee et al. [4] first suggested using a modified RL graft in 2002, many types of autologous interposition vein grafts have been used. We previously described a technique which used an autologous portal vein graft to reconstruct MHV tributaries and the IRHV [4]. One of the crucial problems associated with using RL grafts without the MHV is liver dysfunction caused by excessive congestion [4–6]. Some reports have described the impact of liver congestion [11]. For example, Mizuno et al. [12] demonstrated that the liver regeneration is significantly poorer in a congested area compared with a non-congested area. Congestion should be prevented as much as possible by reconstruction of the IRHV with a suitable interposition graft. However, a suitable vascular graft is not always readily available. As transverse closure of a longitudinal defect does not seem to be ideal for maintaining the cylindrical shape of the IVC, longitudinal closure should be performed. Kubota et al. [13] stated that closure of a 20–30 % defect in the IVC resulted in a 49–64 % decrease in the cross-sectional area. Therefore, patch reconstruction to maintain the flow volume is justified. Various prosthetic and autovenous patch grafts, pericardial grafts and peritoneo-fascial grafts have been described for IVC reconstruction [14–17]. The disadvantages of these methods include the need for additional surgery, the sacrifice of major visceral vessels and the risks of infection. Prosthetic grafts have the advantage of being available in various sizes and can even be used for total replacement of the vena cava, but they carry some risks of infection and thrombosis [14, 15]. The harvesting of autografts, including pericardial
Surg Today
and peritoneo-fascial grafts, always requires additional surgery [14–17]. Harvesting a pericardial patch requires thoracotomy [17]. Harvesting other venous grafts, including saphenous vein, inferior mesenteric vein and internal jugular vein grafts, may result in congestive complications in the areas originally drained by these veins [14, 15]. In contrast, the round ligament is universally available, is of a suitable length and can be harvested during laparotomy without causing the donor any harm [7–9]. There is no need for additional exposure to harvest the round ligament. In addition, it has been shown that the lumen of the round ligament has a mesothelial lining [18]. Rocca et al. [19] and Ribbe et al. [20] reported that such a mesothelial lining is antithrombogenic and promotes endothelialization. These characteristics of the opened round ligament could be advantageous for use as a vascular patch graft, including as a graft in the low-pressure venous system. Yamanaka et al. [21] were the first to demonstrate the feasibility of using the round ligament as a vascular graft. They mainly used the unopened round ligament for reconstruction of the portal system in seven cases of hepatopancreatobiliary surgery. Only one of these cases developed postoperative superior mesenteric vein obstruction and died before hospital discharge, whereas good postoperative patency of the portal system was achieved in the other six cases. Watanabe et al. [8] also reported successful use of the round ligament for patch repair in combination with stents in four cases of iatrogenic injury to the biliary tract, including clipping of the cystic duct, a defect in the common bile duct and right hepatic duct and irregular incision of the common bile duct. None of these patients experienced any further complications. For right-lobe grafts in LDLT, we prioritize the use of the explanted portal vein or internal jugular vein as a tubular conduit graft for reconstructing MHV tributaries, as described previously [5, 6]. Shunt vessels, including the dilated paraumbilical vein, can be used for the same purpose as the second candidate. In addition, a remnant explanted portal vein or an opened round ligament is used as a bridge-shaped patch joining the RHV and the IRHV or as a cuff around the venous orifices. A recent histological analysis of the opened round ligament [22] revealed that only approximately one-third of the round ligaments in adults contained an open umbilical vein, whereas the other two-thirds did not. The opened round ligaments could be used as venous patch grafts without causing thrombosis in the short follow-up periods in those studies; however, the mechanical dilatation of the round ligaments or remnant umbilical veins disrupted the intimal layer and exposed the subintimal layers. Therefore, the limitations of using a round ligament as a venous patch are that it has not been elucidated whether these disruptions of the intimal layers by manual dilatation cause thrombosis
or stenosis in the reconstructed veins during the long term. Further studies with a greater accumulation of cases and longer follow-up are necessary. Our results are not sufficient to allow us to conclude that using a round ligament patch is more effective for achieving long-term patency than other techniques. However, the potential benefits of the procedure warrant further evaluation of this technique, including experience with more cases. Conflict of interest The authors declare no conflicts of interest.
References 1. Raja S, Nery JR, Mies S. Liver transplantation from live donors. Lancet. 1989;2:497. 2. Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Ijichi H, et al. Feasibility of left lobe living donor LT between adults: an 8-year, single-center experience of 107 cases. Am J Transplant. 2006;6:1004. 3. Lee S, Park K, Hwang S, et al. Congestion of right liver graft in living donor liver transplantation. Transplantation. 2007;71:812–4. 4. Gyu Lee S, Min Park K, Hwang S, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation. 2002;74:54–9. 5. Ikegami T, Soejima Y, Taketomi A, et al. Explanted portal vein grafts for middle hepatic vein tributaries in living-donor liver transplantation. Transplantation. 2007;84:836–41. 6. Soejima Y, Ueda N, Fukuhara T, et al. One-step venous reconstruction for a right lobe graft with multiple venous orifices in living donor liver transplantation. Liver Transplant. 2008;14:706–8. 7. Emre S, Schwartz ME, Katz E, Miller CM. Liver resection under total vascular isolation. Variations on a theme. Ann Surg. 1993;217:15–9. 8. Watanabe M, Yamazaki K, Tsuchiya M, et al. Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract. J Hepatobiliary Pancreat Surg. 2007;14:270–5. 9. Ikegami T, Shimada M, Imura S, et al. Beneficial use of the round ligament as a patch graft for vena cava reconstruction. J Hepatobiliary Pancreat Surg. 2008;15:581–4. 10. Shimada M, Shiotani S, Ninomiya M, et al. Characteristics of liver grafts in living-donor adult liver transplantation: comparison between right- and left-lobe grafts. Arch Surg. 2002;137:1174–9. 11. Yonemura Y, Taketomi A, Soejima Y, et al. Validity of preoperative volumetric analysis of congestion volume in living donor liver transplantation using three-dimensional computed tomography. Liver Transplant. 2005;11:1556–62. 12. Mizuno S, Iida T, Yagi S, et al. Impact of venous drainage on regeneration of the anterior segment of right living-related liver grafts. Clin Transplant. 2006;20:509. 13. Kubota K, Makuuchi M, Kobayashi T, et al. Reconstruction of the inferior vena cava using a hepatic venous patch obtained from resected liver. Hepatogastroenterology. 1997;44:378–9. 14. Azoulay D, Andreani P, Maggi U, et al. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg. 2006;244:80–8. 15. Ohwada S, Hamada K, Kawate S, et al. Left renal vein graft for vascular reconstruction in abdominal malignancy. World J Surg. 2007;31:1215–20. 16. Krom RA. Liver transplantation with reconstruction of infrarenal vena cava and iliac veins. Liver Transplant. 2004;10:951–2.
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17. Togo S, Tanaka K, Endo I, et al. Caudate lobectomy combined with resection of the inferior vena cava and its reconstruction by a pericardial autograft patch. Dig Surg. 2002;19:340–3. 18. Tesch C, Henne-Bruns D, Holstein AF. Open lymph vessels of the ligamentum falciforme hepatis in the human. Langenbecks Arch Chir. 1990;375:130–4. 19. Rocca JP, Rodriguez-Davalos MI, Burke-Davis M, et al. Livingdonor hepatectomy in right-sided round-ligament liver: importance of mapping the anatomy to the left medial segment. J Hepatobiliary Pancreat Surg. 2006;13:454–7. 20. Ribbe EB, Alm P, Hallberg E, et al. Evaluation of perito neal tube grafts in the inferior vena cava of the pig. Br J Surg. 1998;75:357–60.
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Surg Today 21. Yamanaka N, Yasui C, Yamanaka J, et al. Recycled use of reopened umbilical vein for venous reconstruction in hepatopancreatobiliary surgery. J Am Coll Surg. 2000;190:497–501. 22. Ikegami T, Wang H, Imai D, Bekki Y, Yoshizumi T, Yamashita YI, Toshima T, Soejima Y, Shirabe K, Maehara Y. Pathological analysis of opened round ligaments as venous patch grafts in living donor liver transplantation. Liver Transplant. 2013;19(11):1245–51.
